Gives a brief overview of major electrolyte imbalances and their management. along with great visual cues to aid learning and recalls

1. Fluid and Electrolyte Imbalance
Acid and Base Imbalance
Dr. Misbah Rafique
Registrar Pediatrics

2. Fluid and electrolyte
Disturbance
Amount and Composition of Body Fluids:
- Approximately 60% of atypical adult’s weight consists of
fluid (water electrolyte).
- Body fluid is located in tow fluid compartment:
1) Intracellular fluids (fluids in the cells) 2/3.
2) Extracellular fluids :( fluids outside the cells) 1/3.
a-Intravascular space (fluids with in blood vessels)
contains plasma.(3L of the total blood).
b- Interstitial fluids: contain fluids that surround the
cell
and total about 8L.eg. Lymph.
c- Transcellular space: contain approximately 1L.
eg. Cerebrospinal, Pericardial, Synovial.

3. Average daily intake and output
in an adult
:
Intake Output
Oral Liquids 1300ml. Urine 1500ml
Water in foods 1000ml. Stool 200ml
Water produced Insensible lungs 300ml
by metabolism 300ml Skin 600ml
2600ml 2600ml

4. Normal Lab Results
:
-
Na 135−145mEq/L
→
.
-
K+ 3.5−5.5mEq/L
→
.
-
Ca++ 8.5−10.5mEq/L
→
.
-
Cl 96−106mEq/L
→
.
-
Mg 1.5−2.5mEq/L
→
.

5. Fluid Volume Disturbance
:
I-Hypovolemia (fluids volume deficit)
:
−
Contributing Factors
:
*
Loss of water and electrolyte
.
e.g.( vomiting,diarrhea,burns)
.
*
Decrease intake. e.g. (anorexia, nausea, inability to
gain access to fluids
.)
*
Some disease.e.g (D.M, Diabetic Insipidus)
.
−
Signs and symptoms
:
Weight loss, general weakness, dizziness, increase pulse
.

6. □ Assessment Diagnostic
evaluation
■Health History & Physical examination
■Serum BUN & Creatinine
■Hematocrit level “greater than normal”
■Urine specific gravity
■Serum electrolytes level
□Hypokalemia in case of GI & renal loss
□Hyperkalemia in case of adrenal insufficiency
□Hypernatremia in case of insensible losses &
↑
diabetic insipidus

8. ♣ Management
treatment of the causes of FVD should be go with
treatment of FVD itself
factors influence the pt fluid needs should be taken in
consideration
In case of severe or acute FVD IV replacement should
be started
Isotonic solutions used to treat hypotension resulted
from FVD
Renal function & hemodynamic status should be
evaluated
♣Nursing Management
Monitor I&O as needed.
Monitor skin turgor , mental status & daily weight
Extensive Hemodynamic CVP, arterial pressure
Mouth care & ↓ irritating fluids

9. Fluid Volume Disturbance
:
II- Hypervolemia (fluid volume excess):
− Contributing Factors:
* Compromised regulatory mechanism such as renal
failure, congestive heart failure, and cirrhosis.
* Administration of Na+ containing fluids.
* Prolonged corticosteroid therapy.
* Increase fluid intake.
− Signs and Symptoms:
Weight gain, increase blood pressure, edema, and
shortness of breathing.

10. Assessment & Diagnostic Evaluation
- Decreased BUN , Creatinine , Serum
osmolality & hematocrit because of plasma
dilution, &↓protein intake
- Urine sodium is increased if kidneys excrete
excess fluid
- CXR may disclosed pulmonary congestion

12. Management
Direct cause should be treated
Symptomatic treatment consist of :
- Diuretics
- restrict fluid & Na intake
- Maintained electrolytes balance
- Hemodialysis in case of renal impairment
- K+ supplement & specific nutrition
Nursing Management:
- Assess breathing , weight ,degree of edema regularly
- I & O measurement regularly
- Semi Fowlers position in case of shortness of breath
- Patient education

13. Electrolyte imbalance
:
I- Sodium Deficit (Hyponatremia):
−Contributing Factors:
* Use of a diuretic.
* Loss of GI fluids.
* Gain of water.
− Signs and Symptoms:
Anorexia, nausea and vomiting,
headache, lethargy, confusion, seizures.

15. Hyponatremia, continued
□Treatment: correct underlying disorder
■Fluid restrict, + diuretics
■Hypertonic saline to increase level 2-3
mEq/L/hr and max rate 100cc of 5%
saline/hr

16. Electrolyte imbalance
:
II- Sodium Excess (Hypernatremia):
− Contributing Factors:
* Water deprivation in patient.
* Hypertonic tube feeding.
* Diabetes Insipidus.
− Signs and Symptoms:
Thirst, hallucination, lethargy,
restless, pulmonary edema.

18. Hypernatremia, continued
□Treatment: correct underlying disorder
■Free water replacement: (0.6 * kg
BW) * ((Na/140) – 1). Slow infusion of
D5W give ½ over first 8 hrs then rest
over next 16-24 hrs to avoid cerebral
edema.

19. Electrolyte imbalance
:
III- Potassium Deficit (Hypokalemia):
− Contributing factors:
* Diarrhea, vomiting, gastric suctions.
* Corticosteroid administration.
* Diuretics.
− Signs and symptoms:
Fatigue, anorexia, nausea, vomiting,
muscle weakness, change in ECG.
■ EKG: low, flat T-waves, ST depression, and U
waves

20. Hypokalemia, continued
□ECG changes in hypokalemia

21. Hypokalemia, continued
□ECG changes in hypokalemia

22. Hypokalemia, continued
□Treatment:
■Check renal function
■Treat alkalosis, decrease sodium intake
■PO with 20-40 mEq doses
■IV: peripheral 7.5 mEq/hr, central 20
mEq/hr and increase K+
in maintenance
fluids.

23. Electrolyte imbalance
:
IV- Potassium Excess (Hyperkalemia):
− Contributing Factors:
* Renal Failure.
* Crush injury, burns.
* Blood transfusion.
* Administration of IV K+.
− Signs and Symptoms:
Bradycardia, dysrhythmia, anxiety, irritable.
- ECG: peaked T waves then flat P waves,
depressed ST segment, widened QRS progressing to
sine wave and V fib.

24. Hyperkalemia – ECG Changes

25. Hyperkalemia – ECG Changes

26. Hyperkalemia, continued
□Treatment:
■Remove iatrogenic causes
■Acute: if > 7.5 mEq/L or EKG changes
□Ca-gluconate – 1 gm over 2 min IV
□Sodium bicarbonate – 1 amp, may repeat in 15
min
□D50W (1 ampule = 50 gm) and 10U regular
insulin
□Emergent dialysis
■Hydration and diuresis, kayexalate 20-50 g, in 100-
200 cc of 20% sorbitol q 4 hrs or enema

27. Calcium
□ Hypocalcemia:
■ Seen in hypoalbuminemia. Check ionized Ca
■ Often symptomatic below 8 mEq/dL
■ Check PTH:
□low may be Mg deficiency
□High think pancreatitis, hyperPO4, low Vitamin D,
pseudohypoparathyroidism, massive blood
transfusion, drugs (e.g. gentamicin) renal
insufficiency
■ S/Sx: numbness, tingling, circumoral paresthesia,
cramps tetany, increased DTR’s, Chvostek’s sign,
Trousseau’s sign
□EKG has prolonged QT interval

29. ECG Changes in Calcium Abnormalities

30. Calcium, continued
□Hypocalcemia cont.
■Treatment:
□Acute: (IV) CaCl 10 cc of 10% solution =
6.5 mmol Ca or Ca Gluconate 10cc of 10%
solution = 2.2 mmol Ca
□Chronic: (PO) 0.5-1.25 gm CaCO3 = 200-
500 mg Ca.
■Phosphate binding antacids improve GI
absorption of Ca
□ Vit D (calciferol) must have normal serum
PO4. Start 50,000 – 200,000 units/day

31. Calcium, continued

32. Calcium, continued
□Hypercalcemia
■Usually secondary to hyperparathyroidism or
malignancy. Other causes are thiazides, milk-
alkali syndrome, granulomatous disease, acute
adrenal insufficiency
■Acute crisis is serum Ca> 12 mg/dL. Critical at
16-20 mg/dL
■S/Sx: N/V, anorexia, abdominal pain, confusion,
lethargy MS changes= “Bones, stone, abdominal
groans and psychic overtones.”

33. Calcium, continued
■Treatment: Hydration with NS then loop
diuretic. Steroids for lymphoma, multiple
myeloma, adrenal insufficiency, bone
mets, Vit D intoxication. May need
Hemodialysis.
□Mithramycin for malignancy induced
hyperCa refractory to other treatment. Give
15-25 mcg/kg IVP
□Calcitonin in malignant PTH syndromes

34. Magnesium
□Hypomagnesemia
■Malnutrition, burns, pancreatitis, SIADH,
parathyroidectomy, primary
hyperaldosteronism
■S/Sx: weakness, fatigue, MS changes,
hyperreflexia, seizure, arrhythmia
■Treatment: IV replacement of 2-4 gm of
MgSO4 per day or oral replacement

35. Magnesium

36. Magnesium, continued
□Hypermagnesemia
■Renal insufficiency, antacid abuse,
adrenal insufficiency, hypothyroidism,
iatrogenic
■S/Sx: N/V, weakness, MS changes,
hyporeflexia, paralysis of voluntary
muscles, EKG has AV block and prolonged
QT interval.
■Treatment: Discontinue source, IV Ca
Gluconate for acute Rx, Dialysis

37. Phosphate
■Treatment: PO replacement (Neutra Phos)
or IV K Phos or NaPhos 0.08-0.20 mM/kg
over 6 hrs
□Hyperphosphatemia
■Renal insufficiency, hypoparathyroidism,
may produce metastatic calcification
■Treat with restriction and phosphate-
binding antacid (Amphojel)

38. Acid−Base Disturbance
:
Normal Values:
PH 7.35- 7.45.
→
PCO2 35-45mmHg.
→
PO2 80-100mmHg.
→
HCO3 22-26mEq/L.
→
Respiratory Acidosis: PCO2.
→ → → → ↑
Respiratory Alkalosis: PCO2.
→ → → → ↓
Metabolic Acidosis: PH,
→ → → → ↓ ↓
HCO3.
Metabolic Alkalosis: PH,
→ → → → ↑ ↑
HCO3.

39. Types of IV solutions
:
* Serum plasma osmalarity (280-300 m osmol).
I- Isotonic Solutions:
A solution with the same osmalality as serum and other body
Fluids.
e.g. N/S 0.9%, Ringer Lactate, D5W.
II- Hypotonic Solutions:
A solution with an osmolality lower than that of serum
plasma.
e.g. half strength saline (0.45% sodium chloride).
III- Hypertonic Solution:
A solution with an osmalality higher than that of serum.
e.g. D/S 0.9%, D/S 0.18%, D/S 0.45%, D10W, D25W.

40. Types of IV solutions
:
*Hypotonic Solutions (0.45%
saline)
□ Decreases intravascular osmolarity.
□ Results in intracellular expansion.
□ Used for cellular dehydration.
□ Complications include shock and
increased ICP.
□ Contraindications include cerebral
edema, and hypotension.

41. Types of IV solutions
:
*Hypertonic Solutions (D5% .45% saline,
D5% NS, D5%LR.)
□ Increases intravascular osmolarity.
□ Results in intracellular and interstitial
dehydration.
□ Used for intravascular expansion by shifting
intracellular and interstitial fluids.
□ Complications include circulatory overload.
□ Contraindications include intracellular
dehydration and hyperosmolar states.

42. Types of IV solutions
:
*Isotonic Solutions (NS, Lactated
Ringers, D5%W.)
□ Does not change osmolarity.
□ Results in TBW expansion.
□ Used to increase intravascular space.
□ Complications include circulatory overload.
□ Contraindications include circulatory
overload and LR in alkalosis and liver
disease.